INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Reading Hospital was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's May 2023 through March 2024 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month as there was no fire drill conducted during the month of January 2024.
This is a repeat citation from the May 4, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A log of monthly fire drills was created by Facilities Management for 2024. Drills will occur during clinic hours. The facilities director will be responsible for ensuring the corrective action is implemented and will contact Facilities Management if a fire drill is not held before the end of each month. The deficiency will be corrected starting April 2024. |
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the development, approval, and ongoing management of treatment/rehabilitation services for clients in four of four applicable client records reviewed.
The policy and procedure manual documented the facility's discharge protocols when a client disengages in treatment and indicated that clients would be discharged within 90 days of inactivity.
Client #4 was admitted on February 13, 2023 and was discharged on April 4, 2024. The client was last seen on February 13, 2023 and did not engage in treatment afterwards. The facility did not discharge client until April 4. 2024.
Client #5 was admitted on February 13, 2023 and was discharged on April 4, 2024. The client was last seen on February 27, 2023 and did not engage in treatment afterwards. The facility did not discharge client until April 4. 2024.
Client #6 was admitted on March 1, 2023 and was discharged on April 4, 2024. The client was last seen on May 10, 2023 and did not engage in treatment afterwards. The facility did not discharge client until April 4. 2024.
Client #7 was admitted on March 8, 2023 and was discharged on April 4, 2024. The client was last seen on March 8, 2023 and did not engage in treatment afterwards. The facility did not discharge client until April 4. 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting on 5/1/24, the Clinical Supervisor will send letters to any patient who has not been seen in 30 days, requesting a response in 10 business days if the patient wants to continue services. Patients who do not respond will be discharged. Facility director will ensure that patients are being discharged in a timely fashion through chart reviews. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of four applicable client records reviewed
Client #1 was admitted on July 24, 2023 and was active at the time of inspection. A treatment plan update was completed on September 25, 2023, and the next update was due no later than November 25, 2023; however, the update was completed on December 11, 2023.
Client #2 was admitted on August 1, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on August 9, 2023, and the first update was due no later than October 9, 2023; however, the update was completed on November 14, 2023.
Client #3 was admitted on December 14, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on December 20, 2023, and the first update was due no later than February 20, 2024; however, the update was completed on April 1, 2024.
This is a repeat citation from the May 4, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, treatment plans will be updated every 60 days. The Facility Director will review charts to ensure that treatment plans are updated every 60 days. |